Why Cardiovascular Disease Is the First Cause

Of Death In Palestine

Nursing research

By:

Shurouq Jamal Al-najjar

Dr- Ayman Abo Ellsos

March, 2021
 i

Abstract

The study explored the relationship between demographic, socio-economic

characteristics and the cardiovascular diseases, and health-promoting behaviors within

the Palestinian populations living in Palestinian.

This analysis study used secondary data from the Palestinian Central Bureau of Statistics.

Gender was found to be associated with having cardiovascular diseases; being a refugee

was associated with being a smoker and having insufficient income.

Correlation of age with cardiovascular disease yielded a positive association. As chronic

disease epidemics gather pace in Palestine and threaten harm to individuals, families, and

the society at large, a comprehensive strategy for risk factor prevention and control is

needed moving the health policy’s from contemplation to action.

 TABLE OF CONTENTS

ABSTRACT i

TABLE OF CONTENTS ii

LIST OF TABLES vi

INTRODUCTION 5

Purpose of the study 8

Research questions 8

Country background 9

Religion and political ideology 10

Review of literature 12

Cardiovascular diseases 15

METHODOLOGY 16

Study design 16

Study instrument 17

Sampling frame 18

Sample size 18

Protection of human subjects 18

 Survey questionnaire 19

Independent variables 19

Gender 19

Age 19

Perceived health status 20

Social support 20

Smoking habit 20

Education attainment 20

Labor force status 21

Income 21

Marital status 21

Dietary habits 21

Physical activity 22

Type of health insurance 22

Data analysis 23

Summary 23

RESEARCH RESULTS 24

Socio-demographic characteristics of the studied population 27

Summary of the results 29

DISCUSSION 37

Research question 38

Summary of findings 41

Recommendations 42

Conclusions 43

REFERENCES 44
 5

Introduction

The Palestinian population, which has reached almost four million, lives in two

separated areas: the West Bank (WB) and the Gaza Strip (GS). It is a young population,

with 46% under the age of 15, and 40% of the population being female who are of

reproductive age (Economic and Social Commission for Western Asia: 2006–2009).

Despite the young age of this population, chronic diseases are a major health concern in

Palestine. There has been a drastic increase in chronic diseases such as cardiovascular

disease, diabetes mellitus, and cancer, which has alerted the interest of epidemiologists

(Husseini, 2009). It is suspected that the chronic war-like conditions generated high

levels of poverty, decreased higher education, and has worsened unemployment. These

factors could have contributed to decreased emphasis on access to healthcare, as well as

health promotions (Giacaman, et el, 2009; World Health Organization- Regional Office

for the Eastern Mediterranean: Health System Profile – Palestine; 2006).

Bureau of Statistics: Primary Results of the National Health Accounts in the Palestinian

Territories, 2010). In turn, the instability of the political structure, as well as the

combative state of the nation, restricts the ability of the Palestinian local government to

fund the healthcare system. This complex socio-political condition created a need for

donors like Non-Governmental Organizations (NGO’s).

 6

Although these organizations are well intended, their assistance alone is not sufficient

protection from the expensive out of pocket payments that Palestinians must contend for

health care (World Health Organization- Regional Office for the Eastern Mediterranean:

Health System Profile – Palestine, 2006, Abu-Zaineh M, et al, 2009)

The elderly make up 4.4 percent (4.8% in the West Bank and 3.7% in Gaza Strip) of the

total Palestinian population and are mostly unemployed, specifically having no job or

working for an unpaid family business. This population does not have a fully

functioning social welfare system, leaving the elderly depending on the immediate

family to cover their financial needs. The Palestinian government does not have laws of

provisions for older adults in terms of rights, benefits, pensions, subsidies or allowances

(Abu Khader, K & Zeidani, M. (2013), and the Palestinian Ministry of Social Affair

(MOSA) provides simple humanitarian assistance with commodities and financial

support for seriously poor elderly (US $90, every three months).Only 3% of the elderly

have financial support from the local government and the rest are the responsibility of

their children. This can be a huge economic burden on the families (United Methodist

Women Resources, 2013). Furthermore, this 22% of the elderly are living in poor

conditions alone or within the extended family household context. (United Methodist

Women Resources, 2013, Abu Khader & Zeidani, 2013).

 7

For the past decades, the political and socio-economic dilemmas of the Palestinian life

made the healthcare system face important challenges in providing adequate services to

its population (Abu-Mourad, et al’ 2008). The Palestinian Health service provision is

inadequate, is subject to sudden discontinuation at any time of extreme political unrest,

and it does not have a substitute plan to address the people’s needs efficiently in such

situation. The political and social instability have caused the healthcare system to evolve

in a very incomplete manner to include four main service providers: the Ministry of

Health (MoH), nongovernmental organization (NGOs), the United Nations, Relief and

Work Agency for Palestinian Refugees (UNRWA) which is specifically targeting

exclusively Palestinian refugees, and private health providers.

Purpose of the study

The purpose of this study is to explore the relationship between Palestinian

demographic and socioeconomic factors and cardiovascular disease.

Research Questions

Research Question. Is there a relationship between age, gender, income, refugee status,

educational attainment, labor force status, marital status, health insurance coverage,

tobacco smoking, dietary habits, physical activity; and cardiovascular disease within

Palestinian population?
 Country Background

Care and other services to the population (Palestinian Central Bureau of Statistics.

Ramallah, 2011). This situation has been restricting the Palestinians who live in Gaza

Strip of their freedom of movement, traveling, trading, employment, and all other social

or business relations with outside the Borders and with the neighboring countries.

Unhealthy living conditions, and limited access to healthcare, threatens the welfare and

public health in Palestine (World Bank Towards a Palestinian State: Reforms for Fiscal

Strengthening. World Bank, 2010).

The Palestinian Territories, which includes West Bank and Gaza Strip, is markedly

undergoing a transition characterized by rapid urbanization (Palestinian Central Bureau

of Statistics; 2011). While Urbanization is changing the Palestinian’s lifestyles, they are

also undergoing an epidemiologic transition characterized by a persistent burden of

infectious diseases, which is typical of the developing countries; and a rise in non-

communicable (chronic) diseases such as cardiovascular disease, hypertension, diabetes

mellitus, and cancer. High prevalence of cardiovascular disease were observed in both

urban and rural Palestinian areas beginning in the late 1990s, and the rates are increasing

since then (Palestinian Central Bureau of Statistics, 2010).

Religion and Political Ideology

Religion and strong beliefs are important when patients approach the healthcare system,

as spiritual and religious beliefs can strongly affect health and illness practices. Some

patients believe that illnesses, such as cancer, or mental illness may be the result of

misfortune or even a punishment from God (Fleming & Towey, 2008). Palestinians

regardless of their religion have one cultural practice, their philosophy of life is shaped

by their culture more than their religious background and may believe that an illness is a

destiny that cannot be changed. Muslims, in particular, center all aspects of their daily

life on praying and reading the Holy Quran, especially for the sick people (Halligan,

2006). They believe reciting the holy Quran often gives comfort and help the gravelly ill

patients to die peacefully. The Christian community includes different denominations

(e.g., Catholic, Orthodox) and is steadfast in faith. Many of the Christian community

believe, like Muslims that health is a gift from God.

The Palestinians who lives in Israel are under Israeli government rules. They have an

access to healthier and wealthier life style, along with access to health care services

(Israeli government's Ministry of Foreign Affairs, 2013). Palestinians living in the West

Bank, including East Jerusalem and Gaza Strip, are under Fatah and Hamas rules,

respectively, and are considered the two main political ideology leaders in the oPT.

Fatah and Hamas have divided the health care systems to provide medical care to their

citizens depending on the physical addresses (Human Rights Council Special Session on

the Occupied Palestinian Territories Human Rights Watch, 2009).

The Ministry of Health of the Palestinian Authority in both WB and GS has a reliable

surveillance system for communicable diseases, aiming to prevent any outbreaks.

This complex structure of the Palestinian’s life has shifted the medical and public health

services to focus on coping with the emergency situation in the country (Jean-Paul,

2009).

Despite the Palestinian Authority having a reliable surveillance health system until

recent years ago, there was no vital statistic registration or reliable information available

on the causes of death. Data on causes of death were registered at the Israeli civil

administration until 1994. After the 1993 Oslo Accords, Palestinians began to collect

information on causes of death in 1994 (Giacaman, 2009).

Improvement in surveillance and vital statistic registration systems, brought by

emergency conditions in 2000, offered the Palestinian Ministry of Health (MoH) the

opportunity to log and describe morbidity and mortality from all different causes in the

West Bank. This also allowed Palestinians to document and focus on mortality from

chronic diseases in adults, which alerted officials to the problem of chronic diseases, and

increased awareness of what has been an unrecognized public health problem (Abu-

Rmeileh, Husseini, Abu-Arqoub, Hamad & Giacaman, 2008).

Review of Literature

The Palestinian Central Bureau of Statistics published that approximately 70.7% of the

elderly aged 60 and over in the Palestinian Territory suffered from at least one chronic

disease during 2010. This was a tremendous increase from 46.5% in the Palestinian

Territory in the year2000 (Palestinian Central Bureau of Statistics, 2010). A survey by

PCBS in 2010 found 22.3% of persons 18 years and above in the Palestinian Territory is

reported as smokers, one of the clinically proven leading causes of cardiovascular

diseases.

Abu-Rmeileh, (2012) conducted a study Analyzing falls in coronary heart disease

mortality in the West Bank between 1998 and 2009; Abu-Rmeileh explored the factors

that were involved in raising the incidence of chronic diseases among Palestinians; such

as a shift from the healthy traditional Middle Eastern diet to a westernization of diet,

particularly junk food and soda which represents real future threat. Furthermore, physical

inactivity that’s accompanies developing obesity and diabetes mellitus, increased

substantially between 1998 and 2009. Obesity prevalence in the year 1998 was 49% for

women and 30% for men aged 35–64 years old. The prevalence of obesity has increased

mainly among men. The 2010 survey conducted by PCBS shows an increase in diabetes

prevalence, which generated approximately 30 additional CHD deaths. Additional

studies need to address the increase of diabetes and obesity, especially among men. This

increase represents a public health priority for immediate effective evidence-based

interventions.
Hussiene (2009) found that cardiovascular diseases, diabetes mellitus, and cancer in the

occupied Palestinian territory were consistent with a previous report based on cause-of-

death statistics from the Israeli-demarcated Jerusalem district. Hussiene (2009)

also stated that the Palestinian mortality rate, caused by coronary heart diseases, is

greater than twice that of the Jewish men and women. Rates of mortality from coronary

heart disease decreased during the study, from 1984 to 1997. Hussiene, 2009 also found

that in Jerusalem the rates of diabetes mellitus and second hand smoking were higher

within Palestinian with coronary heart disease than in Jewish-Israeli with same diagnosis.

Palestinian women were found to have more atypical clinical presentations and more

advanced coronary artery disease than did Jewish women living in the Jerusalem.

Palestinian women were also more likely to be physically inactive, obese, and have

diabetes mellitus than were Jewish women.

Another study by Tayem, 2012 shows that BMI, sedentary lifestyle, and consumption of

fast food has a 27.1% correlation with Pre-hypertension and a 2.2% correlation with

hypertension. Pre-hypertension and hypertension were associated with obesity and

smoking. No relationship was detected between students’ blood pressure and sedentary

behavior, family history of hypertension/coronary artery disease, or consumption of fast

food. The prevalence of increased BMI and blood pressure among males was

significantly higher than females.

Although there is little data available from standardized population-based

epidemiological studies of cardiovascular and cerebrovascular diseases in the occupied

Palestinian territory, five epidemiological studies were done in the West Bank and Gaza

Strip. These cross-sectional studies were based on a sample from the areas in which they

were completed and did not necessarily indicate the national numbers of the general

Palestinian population. However, these studies are able to provide an estimation of the

situation of the chronic diseases. A structured questionnaire was used to obtain

information from participants regarding their demographics, diet, education level, source

of income and physical activity. The rates of diabetes, hypertension, dyslipidemia,

metabolic syndrome, obesity, and other risk factors were based on physical

measurements and blood samples (Tayem Y, 2012).

In summary, Palestinian society, much like that of many other developing countries in

the region, are experiencing an epidemiological transition toward the chronic diseases in

the rise while infectious diseases are another concerns in this country (Giacaman, 2009;

Husseini, 2009).
Cardiovascular diseases

Cardiovascular diseases (CVD) are a class of diseases that involve the heart, the blood

vessels (arteries, capillaries, and veins), or both (Maton et al, Human Biology and

Health, 1993). Cardiovascular disease refers to any disease that affects the

cardiovascular system, principally cardiac disease, vascular diseases of the brain and

kidney, and peripheral arterial disease (Kelly, Fuster & Valentin;Institute of

Medicine;Promoting Cardiovascular Health in the Developing World: A Critical

Challenge to Achieve Global Health,2010).

Cardiovascular disease is a serious health problem; examples of CVD are coronary or

vascular heart disease, cerebrovascular disease (stroke) and cardiomyopathy. The

cardiovascular disease has multiple risk factors, that can occur from a combination

between genetic, family history and life style factors. Genetic factors and family history

has a great influence on someone health outcome, these factors can be modifiable or non-

modifiable. The life style factors are referred to physical inactivity, dietary habits, and

smoking. Being physically active can be determined by the intensity and length of

physical activity. It has a direct effect on individual health, and to be considered

physically active; respondent has to indicate at least thirty minutes of moderate-intensity

physical activity each day for at least five days a week (American Heart Association,

2013). Multiple studies showed that walking at least two hours a week can reduce the

incidence of premature death from cardiovascular disease by about 50%. Moreover,

People with diabetes if they maintain daily physical activity recommended by the CDC

Guidelines; are thought to improve their blood glucose control, and can reduce the

negative impact of diabetes on cardiovascular system (WHO, Global Strategy on Diet,

Physical Activity, and Health, 2014).

 METHODOLOGY

The methodology involved in the completion of this study. The following sections are

included: study design, study instrument, sampling frame, and size, protection of human

subjects, instrument, independent variables, and data analysis.

Study Design

The research will use data from the Palestinian Family Health Survey, which is a national

survey conducted by the Palestinian Central Bureau of Statistics in 2010 of 11, 661

households with a response rate of 88%. The survey compiled health and demographic

information about household members in the selected sample, such as age, sex,

education, participation in labor force, diseases, smoking, and disability; information

about family planning, antenatal care, postnatal care, and fertility from women of

reproductive age; and assessed vaccination coverage and nutritional status of children

younger than 5 years. The information is self-reported and proxy-reported in response to

standard questionnaires.

The target population of the Palestinian Central Bureau of Statistics survey was all

Palestinian households within the West Bank. Descriptive statistics will be run on each

of the study-selected variables, along with bivariate analyses. Relationship will be

further explored between each of the independent the dependent variables. The results

will be used to guide the selection of independent variables that will be included in the

regression models, which will be constructed to determine the effects of each of the

independent variables on the CVD. The analyses will be conducted using IBM SPSS

software, version 20.

Study Instrument

The Palestinian Family Survey 2010 is the fifth in a series of surveys completed by

Palestinian Central Bureau of Statistics (PCBS) over ten years. The first survey

conducted in 1996, the second survey in 2000, the third in 2004, the fourth in 2006, and

the fifth, which is used in this study, was completed in 2010. The survey data of 2010

was used to examine the health status directions of change, compared with previous

surveys in related to demography, elderly, and the transition of population socio-

economic and political context.

The 2010 survey enabled the researcher to analyze demographic and health data that is

attributed to the Palestinian population, which has been defined in the introduction, with

a focus on demography, unmet health needs, education attainment, social support

sources, and perceived health status by elderly.

The 2010 survey includes sections and elements, such as basic health and

socio- economic information of the elderly people 60 years and over. The PCBS hoped

that the research will enable the Palestine decision makers and donor countries to

perform their duties of caring for and promoting health in the Palestinian, as will as

informing planners and policy makers to engage in comprehensive national

development( PCBS, 2010 Survey).

Sampling Frame

The sampling relied on frames established by PCBS and basically includes the list of

clustered areas, which are a geographical areas containing a number of buildings and

housing units of about 120 housing units on average. West Bank: each enumeration area

consists of a list of households with identification data to ascertain the address of

individual households, plus identification data of the housing units (PCBS, Family

Survey, 2010)

Sample Size

The data from an extremely large sample of over 15,355 participants in this study was

reduced to a final sample size of 3,635, which only included those participants who are

60 years and older, and the period of data collection in West Bank was between March

2010, to December 2010.

Protection of Human Subjects

Approval of the PCBS study procedures and the Social Behavioral IRB for social,

behavioral, and educational research performed the verification of the protection of

human subjects for the participants of the study. Selected household who agreed to

participate in the cross-sectional survey were asked to sign an Interview Consent Form

before beginning the questionnaire. Participants were then asked to sign a second

informed consent form before submitting to the Census and Survey Processing System

program (CSPRO). Approval of the use of the PCBS existing data for this study was

obtained from Professor Rita Giacaman, Research, and Program Development

Coordinator at Institute of Community and Public Health (Birzeit University), as noted in

Appendices.
Survey Questionnaire

Household questionnaire: Covers demographic and educational characteristics, chronic

diseases, smoking habits, employment status, and marital status. Elderly questionnaire

(60 years and over): Covers general characteristics, social relations, activities, time-

use, perceived health status, type of health insurance and use of mass media.

Independent variables

The following variables were used in the analysis for this study. They were

obtained from the PCBS data set utilizing the following procedures.

Gender

The survey asked direct question by the interviewer about how many women in the

house to determine the gender of the household residence. The researcher chose this

variable as women usually develop CVD later than men due to nature of female hormone

presence like estrogen.

Age

The participants in the survey divided into the targeted individuals from three age groups,

and this study focused on elderly aged 60 and older. Chronic diseases prevalence

increase with age, by new reports from CDC and WHO concerning chronic disease.
Smoking Habit

Study participants were asked about the number of cigarettes they smoked daily.

They were also asked how long they have been smoking. The participant’s answers

ranged from smoking 10 cigarettes or less per day, 11-20 cigarettes per day, 21-40

cigarettes per day, and more than 40 cigarettes per day. The answers to how long the

participant has been smoking ranged from 1year to 58 years. The researcher created a

new variable called “Number of packs of cigarettes per day”.

When participants smoke 10 cigarettes or less per day, the number was recoded to 0.5

pack of cigarettes; when participants smoke 11-20 cigarettes per day, the number

was recoded to 1 pack of cigarettes; when participants smoke 21-40 cigarettes per day,

the number was recoded to 2 packs of cigarettes; when participants smoke more than 40

cigarettes per day, the number was recoded to more than 2.5 packs of cigarettes. The

“Smoking Habit” variable was created by multiplying the number of packs of cigarettes

per day with the length of years of being a smoker. The variable "Smoking Habits" was

used both as an independent variable, and as a health-promoting behavior in the study

design.

Education Attainment

The survey asked participants about school attendance, and educational status, where

the options ranged from being Illiterate to PhD degree. Educational attainment

explained some of the perceived barriers to action in Pender’s Health Promotion Model.
Labor Force Status (Employment status)

The questionnaire asked the participants how many hours they had of labor force during

the last week, what kind of work they are doing in details, employment status: employer,

self-employed, waged employer and unpaid family member. Employment status

explained some of the situational influences in Pender’s Health Promotion Theory.

Income

The survey asked about the source of income and if the income was sufficient or not,

who supported the household, does the person responding to the questionnaire supports

their self and others. The income variable explained some of the Perceived Barrier To

Actions in Pender’s Health Promotion Theory.

Marital Status

The survey asked participants about their current marital status. Participants chose from:

single, engaged, married, divorced, widow/widower and separated. The researcher

recoded the marital status variable by combining the married and separated participants

into current married category, while the singles, engaged, divorced and widowed were

recoded into current single category. The marital status explained some of the situational

influences in Pender’s Health Promotion Theory.

Dietary Habits

One of the research questions was formed to investigate the Dietary Habits of the

participants in the study. The participants were asked, how many days a week they ate

different types of foods. The researcher classified eating of the following:

Vegetables, Fruits, protein (meat, chicken, fish, and legumes) and carbohydrates (pasta,

rice, bread) as healthy selections. The participants reported the number of times they ate

these choices per week. The researcher classified eating of the following:

Dairy products, fat and oil, and sugars as unhealthy selections. The participants reported

the number of times they ate these choices per week. The researcher added the

categories of the unhealthy dietary habits per week together (scores) and subtracted from

them the healthy dietary habits (scores). This computation provided the dietary habits

score. The variable "dietary habits" was used both as an independent variable and as a

health-promoting behavior in the study design.

Physical Activity

Study participants were asked about engaging in physical activity. One question focused

on whether they walked regularly or not. For those participants who answered yes, they

were asked how many hours they walked in a week? The number of hours walked per

week ranged from 0 to 98 hours in the sample. The number of hours walked per week

indicated the "Physical activity" variable, which used both as an independent variable

and as a health-promoting behavior in the study design.

Type of Health Insurance

The questionnaire asked about medical insurance and the respondent chose either

available, not available, governmental and non-governmental. The health care system in

Palestine is complex and weak, and does not cover all the population health needs.

The new variable calculation, conversion, and recoding were all performed with SPSS.
Descriptive statistics were run on demographic and other variables used for analysis.

Bivariate correlations analyses were run on the dependent and independent variables to

identify possible relationships. Regression analyses were performed using six different

models to test each of the three health-promoting behavior variables of physical

activity, dietary habits, and smoking habits and the three health outcome variables of

hypertension, diabetes mellitus, and cardiovascular disease. Pender’s Health Promotion

Model was used as the framework for the six research questions.

Data Analysis

A total of 2 data files were merged into a single data file using the common participant

identification number as the linking variable. The merged data file from

household/elderly over 60 years old questionnaires in SPSS format was analyzed with

SPSS release 20.0 software. Variable calculation, conversion, and recoding were all

performed as previously discussed in the independent variables section of this chapter.

Frequencies and descriptive statistics were run on demographic and other socio-economic

variables used for analysis. Linear multiple regression analyses were then performed

using six different models to test each of the three health-promoting behavior variables of

smoking habits, dietary habits, and physical activity and the three health outcome

variables hypertension, diabetes mellitus and cardiovascular disease.

 Research Results

Socio-demographic characteristics of the studied population

The data used in this study is from the Palestinian Bureau of Statistics. Elderly and

household surveys were used to analyze and describe the possible correlation between

dependent variables (cardiovascular diseases) and independent variables (age, gender,

income, perceived health status, social support, dietary habits, physical activity, type of

medical insurance, refugee status, employment status, smoking habits, marital status and

education attainment). Descriptive statistics were run on the data. Bivariate correlations

were also used to explore possible relationships between dependent and independent

variable; SPSS (Statistical Package for the Social Sciences) version 21 software was

used.

Using Pender’s Health Promotion Model to examine the Individual Characteristics and

experiences of the participants in the study, another analysis was completed to describe

and correlate possible relationships between dependent variables (dietary habits, physical

activity, smoking habits) with independent personal and socio- demographic

characteristics (age, gender, income, perceived health status, social support, type of

medical insurance, refugee status, employment status, marital status and education

attainment). The total number of the sample is 3635 participants, almost half of the

sample (45%) are male, the mean age of the sample was 69.7 (SD=7.908) and the age of

participants ranged from 60 to 95 years. More than one third of the sample reported their

income as not sufficient (35.1%).

 Non- represented more than half of the sample (55.2%), and the employment status of the

sample was reported as unemployed (89.2%), self-employed (4.5%), while (3.7%) were

waged employees. The participants were found to be mostly illiterate, almost half of the

sample had no means to read or write (48.3%). More than one third of the sample

perceived their health status as average (43.4%), also 7% of the sample reported that they

have no social support from family, friends or neighbors while the rest of the sample had

available social support ranging from one to ten sources, mean 2.6045 (SD=1.34199).

More than half of the participants were married (65.2%), widowed participants composed

the second large group (30.8%).

Table 4.1. Frequencies of socio-demographic characteristics. (N= 3635)

Variable N Percent%

Gender

Male 1637 (45)

Female 1998 (55)

Age group

60-69 2034 (56)

70-79 1093 (30)

80-85 353 (9.7)

>85 155 (4.3)

 Income

Sufficient 2358 (64.9)

Non-sufficient 1275 (35.1)

Refugee status

Refugees 1629 (44.8)

Non-refugees 2006 (55.2)

Employment status

Unemployed 3243 (89.2)

Self employed 163 (4.5)

Waged employee 135 (3.7)

Employer 55 (1.5)

Unpaid family work 39 (1.1)

Education

Illiterate 1757 (48.3)

Semi-illiterate 545 (15)

Less than high school 777 (21.4)

High school graduate 254 (7.0)

Associate diploma 122 (3.4)

 Bachelor degree 145 (4.0)

Post bachelor 7 (0.2)

Master degree 11 (0.3)

PhD 9 (0.2)

Perceived health status

Bad 785 (21.6)

Less than good 628 (17.3)

Average 1577 (43.4)

Very good 499 (13.7)

Excellent 144 (4.0)

Social support

1-3 sources 1828 (50.3)

4-6 sources 547 (15.1)

7-10 sources 4 (0.1)

0 source 7 (0.2)

Marital status

Single 109 (3.0)

Divorced 36 (1.0)

Widowed 1119 (30.8)

Married 2371 (65.2)

The Health Promotion Model was used to explore the demographic, socioeconomic, and

interpersonal influences like social support sources as interpersonal factors and how it

can affect participants’ health promotion behaviors outcomes. Health Promotion

Behaviors like dietary habits, engaging in physical activity, and smoking habits, may

have an effect on health outcomes (Table 4.2, 4.3).

Vegetables and carbohydrates were the most consumed type of food by the

participants, mean values of 4.74, and 4.87 days per week and (SD=2.045, 2.226)

respectively. Dairy products mean value, 3.87 days per week, (SD=2.287), fruits mean

value, 3.26 days per week, (SD=2.193), protein consumption mean value, 2.74 days per

week, (SD=1.778), fat and oil mean value, 2.60 days per week, (SD=2.337), and sugar

mean value, 1.89 days per week, (SD=1.991).

Table 4.2: Mean and Mode values + (SD) for dietary habits per week. (N= 3635)

Variable Mean Mode (SD)

Vegetables 4.74 7 2.045

Fruits 3.26 2 2.193

Protein 2.74 2 1.778

Carbohydrate 4.87 7 2.226

Dairy products 3.87 7 2.287

Fat and oil 2.60 0 2.337

Sugar 1.89 1 1.991

The majority of the participants reported to have 1-9 hours of walking per week,

(16.7%), mean 17.01 (SD=27.907), Physical activity represented by walking regularly

every week, number of hours of walking weekly, varying from one hour to 70 hours,

(25.0%) reported to practice walking regularly, while (74.9%) reported not practicing

walking activity. In table 4.2, frequencies of physical activity with number of hours of

walking per week are displayed.

Almost 89% (86.6%), of this age group reported to smoke more than two and a half

packs of cigarettes a day, mean 2.23 (SD=0.681). The majority of the populations have

governmental health insurance, (75.3%).

Table 4.3: Frequency values and percentage of exogenous variables. (N= 3635)

Variable N Percent%

Physical activity
Practicing walking activity regularly
Yes 909 (25)

No 2724 (74.9)
Number of hours of walking per week

Zero hours 2726 (75)

1-9 606 (16.7)

10-19 129 (3.5)

20-29 58 (1.6)

30-39 15 (0.4)

40-49 6 (0.2)

>50 95 (2.6)
Smoking habits

Half pack of cigarettes/day 486 (13.4)

More than 2.5 packs of cigarettes/day 3149 (86.6)

Type of health insurance

Governmental health insurance 2738 (75.3)

Non-Governmental health 895 (24.6)

insurance

Investigation of healthy behaviors continued by examining the health outcomes, and

exploring frequencies of cardiovascular disease.

Table 4.4 illustrates these frequencies. Approximately 15% reported to having

cardiovascular disease.

Table 4.4: Frequency and parentages and

cardiovascular diseases.

(N= 3635)

Variable N Percent%

Cardiovascular disease 547 (15.0)

Tobacco use varies from using cigarettes, pipes, water pipes (Hookah) or combination of

cigarettes and pipes, or cigarettes and water pipe. The study found (14%) of the

participants smoking mainly cigarettes and pipe, while 4 (1.1%) smokes water pipe only.

Continuing to analyze the smoking habits, (7.2%) reported being a former smoker and

(77.6%) reported as never smoked. Table 4.6: shows frequencies of smoking habits with

amount of consuming tobacco in form of cigarettes. The majority of the smokers reported

to smoke more than two and a half packs of cigarettes a day (86.6%), and (13.4%)

reported to smoke up to half pack of cigarettes daily.

Table 4.6 Frequencies of tobacco use, and amount of consuming of cigarettes per

day.

(N= 3635)

Variable N Percent (%)

None-smoker 2821 (77.6)

Cigarettes and pipe 510 (14.0)

Water pipe 40 (1.1)

Cigarettes and water pipe 4 (0.1)

Former smokers 260 (7.2)

Pack of cigarettes per day

Half pack of cigarettes 486 (13.4)

Two packs of cigarettes and more 3149 (86.6)

Regression was used with smoking habits to evaluate the relationship with the

independent variables; the model was able to predict 16.3 % of the total variance, as

shown in table 4.7.

Table 4.7: linear regression analysis of smoking habits as a dependent variable.

(N= 3635)

Independent variable Unstandardized coefficient β P-value

B

Male Gender -17.580 -.181 .001**

Age 9.588 .292 .000**

Income -2.190 -.042 .416

Governmental medical -2.824 -.050 .327

insurance

Marital status -32.724 -.097 .065

Refugee status 7.404 .143 .005**

Social support -1.956 -.035 .495

Perceived health status .413 .018 .744

R2 .163

Adjusted R2 .138
F( p-value for 6.526
model)

* p < .05 ** p < .01

Table 4.7 shows that males will smoke 17.6 less packs of cigarettes per year, and for

every year an individual gets older, he smoke an additional 9.6 pack of cigarettes per

year. Refugee individuals will smoke an additional 7.404 packs of cigarettes per year.

A regression was used to identify the predictors of physical activity with multiple

independent variables. The model was significant, 6.6% of the total variance was

explained by listed independent variables in table 4.8.

Table 4.8: linear regression analysis of physical activity habit as a dependent

variable.

(N= 3635)

Independent variable Unstandardized β P-value

coefficient

Age -.546 .095 .000**

Age -.546 .095 .000**

Male Gender 1.317 .131 .000**

Income .184 .018 .0395

Refugee status .528 .052 .009*

Education status -.098 -.028 .253

Employment status -.992 -.041 .049*

Marital status .371 .007 .723

Perceived health status .692 .148 .000**

Social support -.299 -.027 .181

R2 .066

Adjusted R2 .062

F(p-value for 16.744

model)

* p < .05 ** p < .01

Males have an additional 1.317 hours of physical activity per week; with every

additional year of age the individuals gain, they have .546 less hours of physical activity

per week. Refugee individuals have an additional .528 hour of physical activity per

week. Unemployed individuals have .992 less hours of physical activity per week, while

individuals with higher score of perceived health status have an additional .692 hour of

physical activity per week.

The cardiovascular diseases are the second set of regression models, as Pender’s Health

Promotion Model is exploring health both promotion behaviors and health outcomes. In

the previous models, the study investigated the prior behaviors of the individuals and

focused on dietary habits, smoking habits and physical activity.

cardiovascular disease was investigated by using also regressions, to predict the

association with other independent variables, the model was significant, and 3.2% of the

total variance was explained by independent variables. Table 4.11; illustrates the results

of the predicting outcome of the model.

In this final part of the analysis of the dependent variables, cardiovascular disease was

investigated by using also regressions, to predict the association with other independent

variables, the model was significant, and 3.2% of the total variance was explained by

independent variables. Table 4.11; illustrates the results of the predicting outcome of the

model.

The table below shows that male individuals are more likely to be diagnosed with

cardiovascular disease. Individuals with smoking habit have an additional 2.3% ( .023 )

chances of being diagnosed with cardiovascular disease and the higher the individuals

have rated their perceived health status scale, the less likely to be diagnosed with

cardiovascular disease 0.048 (4.8%).

Table 4.11: linear regression analysis of cardiac disease as a dependent variable.(N=

3635)

Independent variable Unstandardized coefficient β P-value

Male Gender .038 .052 .038*

Income .018 .023 .287

Refugee status -.024 -.032 .121

Education status .006 .025 .299

Employment status .045 .026 .228

Marital status -.108 -.028 .174

Governmental medical .023 .026 .212

insurance
Smoking habits .023 .061 .006**

Dietary habits -.001 -.012 .569

Physical activity -.003 -.035 .102

Perceived health status -.048 -.139 .000**

Social support -.001 -.003 .900

R2 .032

Adjusted R2 .027
F(p-value for 6.357
model)

* p < .05 ** p < .01

 DISCUSSION

Description of the studied population

This descriptive, correlational study explored the relationship between personal factors

(age, gender, perceived health status), perceived barriers to action (insufficient income,

education attainment, type of health insurance), interpersonal influences (social

support), situational influences (refugee status, marital status, employment status), and

participant’s adherence to health-promoting behaviors (physical activity, dietary habits,

smoking habits), and the overall health outcomes (cardiovascular disease).

Research Question

Is there a relationship between age, gender, income, refugee status, educational

attainment, labor force status, marital status, health insurance coverage, perceived health

status, social support, smoking habits, dietary habits, physical activity; and cardiovascular

disease within Palestinian population?

The results of the regression analysis demonstrate that the model exploring the

relationship between personal factors (age, gender, perceived health status), perceived

barriers to action (insufficient income, education attainment, type of health insurance),

interpersonal influences (social support), situational influences (refugee status, marital

status, employment status); and participants adherence to health-promoting behaviors (

physical activity, dietary habits, smoking habits), and cardiovascular disease.

Three predictor variables, gender, smoking habits and perceived health status,

significantly contributed to the model. Males with smoking habits are more likely to

have a cardiovascular disease, and individuals with low perception of health status are

negatively associated with cardiovascular disease. This suggests that gender and

smoking together with the conventional risk factors of cardiovascular disease, the poor,

elderly, and higher levels of tobacco consumption, increased risk of cardiovascular

disease. Cigarette smoking is prevalent in West Bank, and is one of the risk factors

associated with CVD (Lopez, E. 2003)

In this study, the prevalence of CVD was 15.0%, which is similar in findings to a study

conducted in Gaza Strip about gender and cardiovascular disease. Jamee, Abed &

Jalambo (2013) found the cardiovascular patients to be smokers, with diabetes mellitus,

hypertension, dyslipidemia, and having a family history of cardiovascular disease. The

study also found cases of myocardial infarction was twice in males than females (53.5%

in male, 25.7% in female), and 77.4% of diagnosed coronary artery disease are male,

37.4% were 60 years and older (Jamee, Abed & Jalambo, 2013). This suggests that the

high risk of cardiovascular disease in males might be caused by the social and cultural

norms accepting males to be smokers, while it is not popular to have young females as

smokers, especially in public. In addition, aging is a risk factor for cardiovascular

disease, along with the higher number of years of being smoker and higher number of

cigarettes the individuals’ smokes per day.

The Palestinians and the Israelis both experiences the stressors of the long-term

conflict on daily basis, however the life style for both are widely different (WHO-

MONICA World Health Organization Monitoring Trends and Determinants in

Cardiovascular Disease), The deprivation of power and lack of authority of the

Palestinians supposedly causes chronic stress, which may contribute to an excess

consumption of cigarettes and risk of developing CVDs. Furthermore Israeli

checkpoints create a permanent obstacle, and a physical wall was built surrounding the

Palestinians living areas to prevent free movements through or between communities.

Walking is prohibited through these communities, unless going through those

checkpoints, which form struggle on a daily basis. Nevertheless, the lower

socioeconomic status and low educational level of the Palestinians also plays an

important role in the prevalence of hypertension, diabetes and cardiovascular diseases

(WHO Monica Project, 2005).

Although cardiovascular disease CVD is the leading cause of morbidity and mortality

around the world, diabetes and hypertension are among the risk factors for a person to

have CVDs. Approximately 65% of people with diabetes die from some form of heart

disease (micro and micro-vascular complications) or stroke. It is found that individuals

with diabetes have great risk of developing cardiovascular disease CVD than people

without this metabolic disorder (American Heart Association, 2013). In United States, a

study conducted by Indiana University-Purdue University Indianapolis and the Marion

County Public Health Department (2013) found that a low-income urban neighborhood

on the east side of Indianapolis, had higher prevalence of diabetes, hypertension, heart

disease and stroke than in other areas of Marion County.

These findings are explain the ironic Palestinian socio-economic situation in which,

chronic diseases are highly connected to dietary habits, physical activity, smoking, low

income, and low education level that contribute to these diagnoses. The USDA's

Economic Research Service, 2013 estimates that 23.5 million people in the U.S lack

access to fresh fruits, and vegetables, and relying on pre-prepared meals, which causes

obesity, diabetes, and cardiovascular disease.

Although people have no control over unmodifiable risk factors like age, gender,

ethnicity, and family history, following a healthy diet and engaging in regular physical

activity can prevent obesity, diabetes mellitus and hypertension, which are known to

cause heart disease. A high fat saturated diet contributes to increases in the risk of heart

disease and stroke, and is estimated to cause about 31% of coronary heart disease and

11% of stroke worldwide (World Heart Federation, 2013).

Finally, being a refugee applies to situational influences in Pender’s Health Promotion

Model, and has presumed negative physical, psychological, and financial angles that will

direct certain health behaviors. Unfortunately, it is not feasible to change the individual

refugee status. It is imperative to this vulnerable underserved population to get benefit

from empowerments, and enabling them to be responsible about their own health. A

public health advocacy could be used to help people change unhealthy behaviors to a

healthy one, encourage them to abstain from smoking, be physically active, build a

community with focus groups on refugees, provide them with intensive education about

chronic diseases risk factors, provide picture brochures to include illiterate people with

this education, and media influence can all be a tremendous value in changing unhealthy

behaviors.
Summary of Findings

Here, the study described the demographic characteristics and the health status of the

Palestinian. The study have used not only standard indicators like morbidity, and

mortality rates, but rather used a subjective indicator like elderly’s perception of health

their and the availability of social support system around them. Pender’s Health

Promotion Model used to analyze and understand the behavior-specific cognitions and

effect on health and well-being of the socio-economic and cultural conditions in

Palestine. The study indicated the impact of the non-communicable diseases on the

health system, and concluded that non-communicable diseases risk factors are

influenced by economic, social, and political environment, along with gender and

personal behaviors.

The elderly in Palestine, lacks the access to quality health care services, physically

inactive, have insufficient income, and chronic smokers with no job security or welfare

system. Considering the implications of the research findings for protection and

promotion of health of the Palestinian elderly population, and the relevance of theses

indicators and analytical framework. Pender’s Health Promotion Model was adopted to

emphasize the capability of people to change unhealthy behaviors and adhere to

healthy ones within the context of the daily life obstacles caused by the chronic war

condition. Moreover, it can be easy to propose recommendations, but commitments to

a plan of action to enhance the life style are not easy. Healthy diet, regular physical

activity, and quitting tobacco consumption are among the behaviors that are

challenging to change.
The study has the evidence assembled on the factors that affects health outcomes, and

identifying the needs of elderly. National prevention and control Programs for healthy

nutrition, physical activity, smoking cessation, cardiovascular diseases, are imperative to

improve the health and quality of life of elderly. In addition, the Palestinian should

recognize that the structural, cultural and political conditions that they sustains, is in

consequence with chronic diseases risk factors, but it is possible to minimize the

occurrence of chronic diseases through controlling smoking.

Recommendations

The Ministry of Health in Palestine is supplied by data from PCBS national surveys,

along with the UNRWA and WHO annual reports, that enrich and strengthen the health

system services. Unfortunately, the condition is unlike the developed neighboring

countries in which, the local government of the Palestinian’s lacks the knowledge at large

of elderly health needs leaves them vulnerable to poverty and disabilities caused by

chronic diseases. According to the Palestinian Central Bureau of Statistics in 2010, Life

expectancy has increased from 67 years in 1992 to 71.3 years in 2012 for males, and

from 67 years to 74.1 years for females, this increase in Palestinians’ life expectancy,

stresses out the need for long-term programs directed toward geriatric health. In the

scope of National Burden of non-communicable diseases, emerges the need to develop

Health Promotion environment for the society, especially for the poor and disadvantaged

communities, includes elderly.

The Ministry of Health needs to re-orient the healthcare professionals. The Palestinian

Ministry of Health, the UN Relief and Work Agency, non-governmental organizations,

and the private medical sector, needs updated education about the complex health needs

of the elderly. A comprehensive national policy based on medical-social programs for

ageing people would be valuable. These national policies maintaining a safe access to

high quality health services, and initiating routine screening for early detection of

cardiovascular disease, especially for individuals who are obese, smokers, and physically

inactive. Elderly with poor economic status could benefit from initiating income security

programs to respond to the financial needs of the elderly.

Conclusions

The understanding of the risk factors of non-communicable diseases is valuable in

planning for preventions. WHO reported that these diseases are “preventable” by

educating the society. Starting with the healthcare providers, increasing public health

literacy, and health promotion behaviors are the activities that should be emphasized.

Public health awareness may reduce most of the non-communicable disease risks

through regular physical activity, avoiding tobacco consumption and passive smoking,

adopting a healthier dietary habit with increase consumptions of vegetable and fruit, not

using food containing fat, salt, sugar, and maintaining a healthy body weight (WHO,

International plan of action on aging: report on implementation, 2014).

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